Laserfiche WebLink
CITY OF STOCKTON <br /> DEPARTMENT OF PUBLIC WORKS 65388 <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> Ago <br /> 1A9pplicant's Name /+�'�Tr!�� ' ' Date rI <br /> (Ow ner/Contractor) //� <br /> l /0 ��tl <br /> Address # n� � / -_7 — Phone <br /> / <br /> APPROVED: PUBLIC WORKS DIRECTOR <br /> City 5S-62C,9JM --- _ -..._state Zip !7?C — <br /> Location of Propos work,etc. <br /> Ovmed Contractor Address (Sf ?T / (� B pate <br /> Estimating Starling Date -�!u� Completion pate Lr'�7- Permit Expiration Date L <br /> I(or We)hereby apply for an enroachment permit to carry out the following work: <br /> Y -- t <br /> The above named appticant hereby requests permission to- <br /> PERMIT FEE..........................................$ t <br /> Additional Footage Fee...........................$ <br /> Sewer Tap Deposit................................. <br /> TOTAL DEPOSIT .............S <br /> I Building Permit No. <br /> I Improvement Plan No. <br /> Supplemental Conditions: . <br /> ' Ab Lax- C 1osury s <br /> r <br /> i <br /> I Show sketch above or refer to drawing submitted <br /> IMPORTANT: Applicant hereby agrees to comply with all provisions of this permit as well as all applicable City ordinances, resolutions, <br /> standards and specifications currently in elect, and to pay to City its actual cost for removal and proper replacement of any item which <br /> does not meet above requirements. Failure to comply will be cause for revocation of permit. Applicant agrees to indemnify and hold the <br /> City harmless against any and all losses, costs, or damages resulting from injury to persons, death of person or damage to property <br /> occuring at the site of, or as a result of, work to be performed under this permit. A certificate of insurance shall be submitted to the City <br /> Risk Manager prior to beginning construction. <br /> PERMITTEE SHALL CONTACT UNDERGROUND SERVICE ALERT (1-800-642-2444) TWO WORKING DAYS BEFORE BEGINNING <br /> WORK FOR LOCATION OF UNDERGROUND UTILITIES. <br /> PERMITTEE SHALL CALL (209) 9371.2A�-HOURS PRIOR TO START OF WORK FOR A CONTROL NUMBER AND TO SCHEDULE <br /> INSPECTION. q <br /> Read General Provisions on reverse side of this permit before signing - Note requirement of notificatitiiio'/�ns+'/�and inspections. <br /> Signed: !. `� r`^ _Phone,—k✓ L •"�f f <br /> 1s1-Permittee 2nd-File 3rd-Finance 4th•L-Mdity/Street <br />